List below all present and past employment, beginning with your most recent.

Name and Address of Company

Start Date

End Date

Type of Business and Phone #:

Start Salary

End Salary

Position

Reason for Leaving

Name and Address of Company

Start Date

End Date

Type of Business and Phone #:

Start Salary

End Salary

Position

Reason for Leaving

Name and Address of Company

Start Date

End Date

Type of Business and Phone #:

Start Salary

End Salary

Position

Reason for Leaving

Name and Address of Company

Start Date

End Date

Type of Business and Phone #:

Start Salary

End Salary

Position

Reason for Leaving

Criminal Record

Have you been convicted of a crime* other than a misdemeanor?

If Yes, when, where, and nature of offense

(A conviction will not automatically bar you from employment. Each conviction will be evaluated on its own merits with respect to the offense, the date of the conviction, and the sentence imposed. All circumstances will be considered).

*In Ohio, do not list sealed convictions, unless directly related to the position sought.

Employment Data Record:

Employees are treated during employment without regard to race, color, religion, sex, national origin, age, marital or veteran status, medical condition or handicap, or any other legally protected status. As an employer with an Affirmative Action Program, we comply with government regulations, including Affirmative Action responsibilities where they apply.

The purpose for this Data Record is to comply with government record keeping, reporting, and other legal requirements. Periodic reports are made to the govemment on the following information. The completion of this Data Record is optional. If you choose to volunteer the requested information please note that all Data Records are kept in a Confidential File and are not a part of your Application for Employment or personnel file. Please note: YOUR COOPERATION IS VOLUNTARY. INCLUSION OR EXCLUSION OF ANY DATA WILL NOT AFFECT ANY .EMPLOYMENT DECISION:

Applicant's Statement:

I certify that answers given herein are true and complete to the best of my knowledge. I authorize investigation of all statements contained in this application for employment as may be necessary in arriving at an employment decision.

This application for employment shall be considered active for a period of time not to exceed 45 days. Any applicant wishing to be considered for employment beyond this time period should inquire as to whether or not applications are being accepted at that time.

I hereby understand and acknowledge that, unless otherwise defined by applicable law, any employment relationship with this organization is of an "at will'' nature, which means that the Employee may resign at any time and the Employer may discharge Employee at any time with or without cause. It is further understood that this "at will" employment relationship may not be changed by any written document or by conduct unless such change is specifically acknowledged in writing by an authorized executive of this organization.

In the event of employment, understand that false or misleading information given in my application or interview(s) may result in discharge. I understand, also, that I am required to abide by all rules and regulations of the employer.